MEDICAID MODEL DATA LAB

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1 MEDICAID MODEL DATA LAB Id: OHIO State: Ohio Health Home Services Forms (ACA 2703) Page: 1-10 TN#: OH Superseeds TN#: OH Effective Date: 10/01/2012 Approved Date: 09/17/2012 Transmital Numbers (TN) and Effective Date Please enter the numerical part of the Transmital Numbers (TN) in the format YY-0000 where YY = the last two digits of the year for which the document relates to, and 0000 = a four digit number with leading zeros. The dashes must also be entered. State abbreviation will be added automatically. Supersedes Transmital Number (TN) Transmital Number (TN) Please enter the Effective Date with the format MM/dd/yyyy where MM = two digit month number, dd = the two digit day of the month, and yyyy = the four digit year. Please also include the slashes (/). Effective Date 10/01/ A: Categorically Needy View Attachment 3.1-H Page 1 Health Homes for Individuals with Chronic Conditions Amount, Duration, and Scope of Medical and Remedial Care Services: Categorically Needy Notwithstanding anything else in this State Plan provision, the coverage will be subject to such other requirements that are promulgated by CMS through interpretive issuance or final regulation Health Home Services How are Health Home Services Provided to the Medically Needy? Not provided to Medically Needy i. Geographic Limitations Targeted Geographic Basis If Targeted Geographic Basis, Health home services will be implemented on a targeted geographic basis. The geographic areas to be implemented as of the effective date of this SPA are Butler County, Adams County, Scioto County, Lawrence County, and Lucas County. ii. Population Criteria The State elects to offer Health Home Services to individuals with: Two chronic conditions One chronic condition and the risk of developing another One serious mental illness from the list of conditions below: Mental Health Condition Substance Use Disorder Asthma Diabetes Heart Disease 1/31

2 BMI Over 25 Other Chronic Conditions Covered? Description of Other Chronic Conditions Covered. iii. Provider Infrastructure Designated Providers as described in ection 1945(h)(5) The State will establish Medicaid health homes for beneficiaries who meet the State s definition of serious and persistent mental illness (which includes adults with serious mental illness [SMI] and children with serious emotional disturbance [SED]), initially using a regional approach. Ohio s Community Behavioral Health Centers (CBHCs) will be eligible to apply to become Medicaid health homes for Medicaid beneficiaries with SPMI. The goals of Ohio s CBHC health homes for Medicaid beneficiaries with SPMI are aligned with those of CMS. They are as follows: improve the integration of physical and behavioral health care; lower the rates of hospital emergency department (ED) use; reduce hospital admissions and re-admissions; reduce healthcare costs; decrease reliance on long-term care facilities; improve the experience of care, quality of life and consumer satisfaction and improve health outcomes. Moreover, we fully expect to achieve better care coordination and management of health conditions as well as increase the use of preventive and wellness management services. Ohio will employ a two-prong approach to assure access for those eligible Medicaid beneficiaries with SPMI to health homes in targeted geographic regions based upon consumer choice. 1. Eligible Medicaid beneficiaries with SPMI, who are currently being served at a CBHC who is an eligible health home, will be oriented to and engaged in the health home by the CBHC health home. These beneficiaries will be notified by the CBHC health homes and will be given the option of opting out of health home services. Additionally, should beneficiaries desire to receive health home services from another health home provider they will be able to do so. Eligible Medicaid beneficiaries with SPMI who are currently being served at a CBHC that is not a health home will have the option of receiving health home services at one of the CBHC health home sites in their targeted geographical region. 2. Those beneficiaries presenting in the hospital ED, or as an inpatient, who appear to possibly meet the criteria for health home services may be referred to a health home provider in their geographic area. Similarly, referrals to health homes may come from specialty providers, primary care providers, managed care plans or other sources in the community. For these new referrals, eligibility for health home services will be determined at the CBHC health home. CBHC health homes will be responsible for notifying other treatment providers about the goals and types of health home services as well as encouraging participation in care coordination efforts. In addition, the state will notify eligible Medicaid Beneficiaries within targeted geographical regions via U.S. mail and other methods necessary about the availability of health home services. The state also plans to partner with the consumer and family advocacy organizations to develop consumer and family education programs about Medicaid Health Homes. NAMI-Ohio and Ohio Empowerment Coalition will assist the departments in efforts to educate and inform family members and consumers regarding the availability of health home services. Community behavioral health centers will serve as designated providers for individuals with SPMI and deliver services through a multidisciplinary team of health care professionals. CBHCs will be required to meet state-defined qualifying core elements that assure coordination of comprehensive medical, behavioral, long-term care and social services that are timely, quality driven and integrated. CBHC health homes will be required to demonstrate the integration of behavioral health and primary care services by directly providing or establishing written agreements with primary care practices. A health home must provide a minimum level of medical screening and treatment services consistent with current professional standards of care. CBHC health homes will be required to establish written agreements with primary care practices that support bi-directional, integrated care. Additionally, CBHC health homes are required to establish partnerships and coordinate with other health care resources to address identified client needs, which include, but are not limited to: hospitals, medical service providers, specialists (including OB/GYNs and substance abuse treatment specialists), long-term care service and support providers, managed care plans and other providers as appropriate to meet beneficiaries needs. Each CBHC health home must establish a health home team led by a dedicated Care Manager who will provide health home services, and coordinate and facilitate beneficiaries access to services in accordance with a single, integrated care plan. The CBHC must also identify other health care team members necessary to comprehensively and holistically meet the beneficiaries needs. While the composition of the team of health care professionals is flexible and is expected to change as the needs of the health home beneficiary change over time, the health home team provides consistency and continuity of care for the beneficiary. Medical leadership is essential to systematically implement standards of quality care. Clinical personnel with experience in Patient Centered Medical Home transformation shall espouse the expertise of change improvement science (e.g., IHI s Breakthrough Series Model) to drive enhanced system performance leading to improved clinical outcomes. To that end, the Embedded Primary Care Clinician is integral to the success and demonstration of integrated care in CBHC health homes. The Embedded Primary Clinician assesses, monitors and consults on the routine, preventive, acute and chronic physical health care needs of clients. Core CBHC health home team members and roles: - Health Home Team Leader: Provides administrative and clinical leadership and oversight to the health home team and monitors provision of health home services. A key function of the Team Leader role is to champion for health home services and motivate and educate other staff members. The Health Home Team Leader must possess a strong health management background and an understanding of practice management, data management, and managed care. The Health Home Team Leader must also have training and experience in quality improvement. The Health Home Team Leader will monitor and facilitate clinical processes and components of Health Homes, which include but are not limited to: consumer identification and engagement; completion of comprehensive health and risk assessments; development of care plans; scheduling and facilitation of treatment team meetings; provision of health home services; monitoring consumer status and response to health coordination and prevention activities; and development, tracking and dissemination of outcomes. The additional clinical and administrative duties will include hiring and training of staff, providing feedback regarding staff performance, conducting performance evaluations, providing direction to staff regarding individual cases, and monitoring overall team performance and plan for improvement. - Embedded Primary Care Clinician: Participates in the provision of health home services including identification of consumers, assessment of service needs, care plan development, development of treatment guidelines, and monitoring of health status and service use. The Embedded Primary Care Clinician will provide education and consultation to the health home team and other team members regarding best practices and treatment guidelines in screening and management of physical health conditions as well as engage with, and act as liaison between, the treating primary care provider and the team. The Embedded Primary Care Clinician will also meet with Care Managers individually to review challenging and complex cases as needed. The Embedded Primary Care Clinician role can be conducted by any of the following professionals: primary care physicians, pediatricians, gynecologists, obstetricians, Certified Nurse Practitioners with a primary care scope of practice, Clinical Nurse Specialists with a primary care scope of practice, and Physician Assistants. It is strongly preferred that the Embedded Primary Care Clinician also functions as the treating primary care clinician whenever possible and may hold dual roles on the health home team. - Care Manager: Is accountable for overall care management and care coordination and able to both provide and coordinate all health home services. A single care management record will be agreed to and shared by all team professionals and patient case reviews will be conducted on a regular basis. The Care Manager will be responsible for overall management and coordination of the beneficiary s care plan which will include both medical/behavioral health (including substance abuse), long-term care, and social service needs and goals. Care Managers can utilize Qualified Health Home Specialists in the provision of some components of health home services. Care Managers must have the necessary credentials and skills to be able to conduct comprehensive assessments and treatment planning. Care Managers will have formal training as well as practical experience in behavioral health and possess core and specialty competencies and skills in working with the SPMI population. Care Managers will also need to demonstrate either formal training or a strong knowledge base in chronic physical health issues and physical health needs of the SPMI population and must be able to function as a member of an inter-disciplinary team. Finally, Care Managers must be knowledgeable and experienced in community resources and social support services for the SPMI population. 2/31

3 - Qualified Health Home Specialist: Assists and supports Care Managers with care coordination, referral/linkage, follow-up, family/consumer support and health promotion services and may include Peer Support Specialists as well as other health professionals or credentialed personnel with commensurate experience. CBHCs will be supported in transforming service delivery by participating in statewide learning activities. Given CBHCs varying levels of experience with organizational change and clinical best practice implementation, the State will assess providers to determine learning needs. CBHCs will therefore participate in a variety of learning supports, up to and including learning communities, specifically designed to instruct CBHCs in the provision of health home services utilizing a whole person approach which integrates behavioral health, primary care, long-term care services and supports, and other needed services and supports. Learning activities may be supplemented with ongoing health home team calls to reinforce the learning sessions, technical assistance, and periodic program reporting (data and narrative) and feedback. Learning activities will support providers of health home services in addressing the following components: - Providing quality-driven, cost-effective, culturally appropriate, and person- and family-centered health home services; - Coordinating and provide access to high-quality health care services informed by evidence-based clinical practice guidelines; - Coordinating and providing access to preventive and health promotion services, including prevention of mental illness and substance use disorders; - Coordinating and providing access to mental health and substance abuse services; - Coordinating and providing access to comprehensive care management, care coordination, and transitional care across settings (transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care); - Coordinating and providing access to chronic disease management, including self-management support to individuals and their families; - Coordinating and providing access to individual and family supports, including referral to community, social support, and recovery services; - Coordinating and providing access to long-term care supports and services; - Developing a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services; - Demonstrating a capacity to use health information technology to link services, facilitate communication among team members and between the health home team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate, and; - Establishing a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level. Team of Health Care Professionals as described in ection 1945(h)(6) Health Team as described in ection 1945(h)(7), via reference to ection 3502 iv. Service Definitions Comprehensive Care Management Service Definition Comprehensive care management begins with the identification of individuals who are potentially eligible to receive health home services. The CBHC health home will be responsible for identifying individuals with severe and persistent mental illness who are currently affiliated with the health home site. SPMI individuals without a CBHC affiliation or a routine source of health care may be identified through referral from another provider or an administrative data review and connected to a CBHC health home to begin the comprehensive care management process. The next step is for the CBHC to engage the eligible individual and his/her family by explaining the benefits of participation and receiving health home services, and the right to opt-out of health home services. The CBHC health home will complete a comprehensive assessment of the individual s physical health, behavioral health (i.e., mental health, substance abuse disorders), long-term care and social needs. The assessment must account for the cultural and linguistic needs of the individual and use relevant comprehensive data from a variety of sources, including the individual/family, caregivers, medical records, team of health professional, etc. At a minimum, the CBHC health home will reassess the individual at least once every ninety days. Based on the health assessment, the CBHC health home will assemble a team of health professionals, and establish and negotiate roles and responsibilities for each member of the team, including the accountable point of contact. The CBHC health home will develop and continuously update a single, integrated, person-centered care plan that will include prioritized goals and actions with anticipated timeframes for completion and will reflect the individual s preferences. Prior to implementation of the care plan, a communication plan must be developed to ensure that routine information exchange (clinical patient summaries, medication profiles, updates on patient progress toward meeting goals), collaboration, and communication occurs between the team members, providers, and the individual/family. The CBHC health home will frequently and routinely monitor the care plan to determine adherence to treatment guidelines and medication regimes, barriers to care, or any clinical and non-clinical issues that may impact the individual s health status or progress in achieving the goals and outcomes outlined in the care plan. As part of the monitoring, the CBHC and team of health professionals are expected to adhere to the communication plan when providing updates and progress reports on the individual. The Health Home Team Leader, the Embedded Primary Care Clinician, and the Care Manager will participate in the comprehensive care management activities and the comprehensive care management service components will be delegated among the health home team members as follow: The health home Team Leader will be responsible for initially screening all new referrals, tracking and facilitating transfer/transition of new cases on to the health home team. The Team Leader will also be responsible for reviewing the list of new cases with the entire team during regular team meetings and assigning each health home enrollee to a designated Care Manager and Qualified Health Home Specialist based on the individual s preferences, needs and staff availability. The other team members can also help identify and facilitate transition of new cases to the team in collaboration with the Team Leader. A licensed clinician Care Manager will be responsible for a designated caseload, completion of the CBHC s standardized health risk assessment, as well as the CBHC s comprehensive health assessment and care plan including a crisis plan with input from other team members. The Care Manager will support and engage the individual and family in the assessment process and the development of care plan which will include the prioritization of goals. The Embedded Primary Care Clinician will be responsible for reviewing the assessment and health data and formulating goals/interventions for physical health care which will be included in the care plan. The Care Manager will provide specific interventions for managing chronic diseases identified in the assessment and care plan under the supervision of the Team Leader and in consultation with the primary care clinician. All members of the health home team will routinely monitor the enrollee s symptoms and functioning, and conduct ongoing assessment of the enrollee s needs. The Team Leader will review and monitor timeliness and quality of assessments and care plans, and ensure that health home enrollees receive comprehensive care management service. The Team Leader and Embedded Primary Care Clinician may also complete some components of the comprehensive assessments and care plans and provide specific care management interventions. The methods of health home services delivery will consist of: service delivery to the beneficiary and may include other individuals who will assist in the beneficiary s treatment; service delivery may be face-to-face, by telephone, and/or by video conferencing; service delivery may be in individual, family or group format; and service delivery is not site-specific and the health home services should be provided in locations and settings that meet the needs of the health home beneficiary. Ways Health IT Will Link The State will phase-in use of HIT to support the delivery of CBHC health home services. In recognition of the varying levels of HIT (i.e., electronic medical records, registries, etc.) utilized by CBHC health homes, the State will initially require that CBHC health homes are able to receive utilization data electronically from a variety of sources. The data will, at a minimum, include clinical patient summaries (e.g., diagnosis, medication profiles, etc.) and real-time notifications of a patient s admission to, or discharge from, an emergency department 3/31

4 or inpatient facility. Within twelve months of receiving designation as a Health Home provider, the CBHC must acquire (or adopt) an electronic health record product that is certified by the Office of the National Coordination for Health Information Technology. Within twenty-four months of receiving designation as a health home provider, the CBHC must demonstrate that the electronic health record is used to support all health home services, including population management. The CBHC health home will also be required to participate in the statewide Health Information Exchange, when available in their region. Following auto-assignment of beneficiaries into health homes and as part of initial Comprehensive Care Management activities, CBHCs will receive health utilization profiles on health home beneficiaries. CBHC health homes will also be required to develop internal processes in order to act on and disseminate the data and demonstrate how data will be utilized to continue ongoing Comprehensive Care Management services. Utilization profiles may be supplied to the CBHC health home no less than quarterly. Care Coordination Service Definition Care coordination is the implementation of the single, integrated care plan. With a person-centered focus, the CBHC will facilitate and direct the coordination, communication, and collaboration which is necessary for the individual to demonstrate progress on the goals/actions of the care plan and achieve optimal health outcomes. This will include, but not be limited to, the following: providing assistance to the consumer in obtaining health care (i.e., primary and specialty medical care, mental health, substance abuse services and developmental disabilities services, long-term services and supports, and ancillary services and supports); performing medication management and reconciliation; tracking tests and referrals with the necessary follow up; sharing the crisis plan, assisting with and coordinating prevention, management and stabilization of crises and ensuring post-crisis follow-up care is arranged and received; participating in discharge planning; and making referrals to community, social and recovery supports. The CBHC health home will be required to assist the individual with making appointments and validating that the services were received by the individuals. Although care coordination requires participation of all health home team members in implementation of the care plan, the Care Manager will have the lead care coordinator role across all providers and settings. The Embedded Primary Care Clinician may have a lead role for the coordination of physical health care needs and communication with the treating primary care clinician and medical specialists as appropriate. The Team Leader will take the lead for developing general care coordination and communication protocols for use with external and internal providers. The Team Leader will also serve as the universal point of contact and care coordinator for all consumers on the team and be the back-up for the Care Manager and Qualified Health Home Specialist. The Care Manager will utilize Qualified Health Home Specialists in coordinating some aspects of the care plan such as referrals to specialists, implementation of discharge plan, accessing housing and other community resources, and obtaining entitlements. The Care Manager will also need to coordinate with other team members such as the nurse on medication management and reconciliation, tracking of labs and results of consults. The methods of health home services delivery will consist of; service delivery to the beneficiary and may include other individuals who will assist in the beneficiary s treatment; service delivery may be face-to-face, by telephone, and/or by video conferencing; service delivery may be in individual, family or group format; service delivery is not site-specific and the health home services should be provided in locations and settings that meet the needs of the health home beneficiary. Ways Health IT Will Link The State will phase-in use of HIT to support the delivery of CBHC health home services. In recognition of the varying levels of HIT (i.e., electronic medical records, registries, etc.) utilized by CBHC health homes, the State will initially require that CBHC health homes are able to receive utilization data electronically from a variety of sources. The data will, at a minimum, include clinical patient summaries (e.g., diagnosis, medication profiles, etc.) and real-time notifications of a patient s admission to, or discharge from, an emergency department or inpatient facility. Within twelve months of receiving designation as a Health Home provider, the CBHC must acquire (or adopt) an electronic health record product that is certified by the Office of the National Coordination for Health Information Technology. Within twenty-four months of receiving designation as a health home provider, the CBHC must demonstrate that the electronic health record is used to support all health home services, including population management. The CBHC health home will also be required to participate in the statewide Health Information Exchange, when available in their region. In the delivery of Care Coordination services, all CBHC health homes will be required to use utilization data and other information to develop /update the integrated care plan, establish relationships with treatment providers (e.g., hospital, LTC, Rx), share information with other providers to facilitate their treatment of clients, conduct medication management and reconciliation, connect clients with necessary social supports, utilize lab portals to retrieve or develop auto-generated letters that notify PCPs of lab values. CBHC health homes will also be required to develop and utilize tracking systems (e.g., track women who are recommended to have a mammogram) to identify delivered and needed services that links to the Care Management plan. In addition, CBHC health home must have the ability to take patient summary info and place it in formats that are useful for the client. If available, develop a unified care plan electronically. If the client chooses not to receive primary care services at the CBHC health home site, then the CBHC must demonstrate how primary care is integrated at the CBHC site. Health Promotion Service Definition Health promotion services are intended to equip the individual/family with relevant knowledge and skills which will: increase his/her understanding of diseases/conditions identified in the assessment, promote self-management, and improve quality of life and daily functioning. This may be accomplished through the following examples: education about wellness and healthy lifestyle choices; provision of or referrals to evidence based wellness programs, such as Tobacco Cessation, Weight Management, Chronic Disease Management Programs, Wellness Management and Recovery, etc.; and connections to peer supports. A focus of health promotion will be to support and engage the individual and the family in the development, implementation and monitoring of the care plan. By empowering the individual and promoting self-advocacy, there will be an increased ability to be proactive in the self-management of existing conditions, increase the utilization of preventative services, and accessing care in appropriate settings. Health promotion can be provided by any member of the health home team. The Care Manager, as the accountable point of contact has the lead responsibility for providing or arranging for health promotion services based on the identified needs in the assessment and goals in the care plan. All members of the team will be able to educate clients and families regarding the primary condition and chronic diseases and teach self-management skills. The Embedded Primary Care Clinician will provide education on physical health and preventive care as needed. Other health promotion services such as tobacco cessation and treatment may be provided by a Care Manager or Qualified Health Home Specialist with specialized training or Tobacco Treatment Specialist certification. Care Managers and Qualified Health Home Specialists with peer background will co-lead Chronic Disease Self-Management Programs (CDSMP), Wellness Management and Recovery (WMR), and Wellness Recovery Action Plans (WRAP) groups. The Team Leader will have the responsibility for reviewing patient data and developing health promotion programming and resources with input from the team. The Team Leader will also provide direct training or arrange ongoing in-service training for Care Managers and Qualified Health Home Specialists in evidencebased health promotion interventions and monitor provision of health promotion services. The methods of health home services delivery will consist of; service delivery to the beneficiary and may include other individuals who will assist in the beneficiary s treatment; service delivery may be face-to-face, by telephone, and/or by video conferencing; and service delivery may be in individual, family or group format; service delivery is not site-specific and the health home services should be provided in locations and settings that meet the needs of the health home beneficiary. Ways Health IT Will Link The State will phase-in use of HIT to support the delivery of CBHC health home services. In recognition of the varying levels of HIT (i.e., electronic medical records, registries, etc.) utilized by CBHC health homes, the State will initially require that CBHC health homes are able to receive utilization data electronically from a variety of sources. The data will, at a minimum, include clinical patient summaries (e.g., diagnosis, medication profiles, etc.) and real-time notifications of a patient s admission to, or discharge from, an emergency department or inpatient facility. Within twelve months of receiving designation as a Health Home provider, the CBHC must acquire (or adopt) an electronic health record product that is certified by the Office of the National Coordination for Health Information Technology. Within twenty-four months of receiving designation as a health home provider, the CBHC must demonstrate that the electronic health record is 4/31

5 used to support all health home services, including population management. The CBHC health home will also be required to participate in the statewide Health Information Exchange, when available in their region. HIT supports for Health Promotion involves CBHCs use of electronically received health utilization profiles that connect clients with necessary social supports via phone, fax or web- based commensurate with providers capacity and referral source requirements. Comprehensive Transitional Care (including appropriate follow-up, from inpatient to other settings) Service Definition Comprehensive transitional care services are designed to ensure continuity of care and prevent unnecessary inpatient readmissions, emergency department visits and/or other adverse outcomes, such as homelessness. The CBHC health home will develop arrangements with inpatient facilities, emergency departments and residential facilities for prompt notification of an individual s admission and/or discharge to/from a hospital emergency department, inpatient unit or residential facility. The CBHC health home will coordinate and collaborate with inpatient facilities, hospital emergency departments, residential facilities and community partners to ensure that a comprehensive discharge plan and/or transition plan, and timely and appropriate follow up is completed for an individual who is transitioning to/from different levels and settings of care. The CBHC health home will conduct and/or facilitate effective clinical hand offs that include timely access to follow-up post discharge care in the appropriate setting, timely receipt and transmission of a transition/discharge plan from the discharging entity, and medication reconciliation. The Care Manager will be the accountable team member for providing comprehensive transitional care service including the development and coordination of a discharge and transition plan. However, other members of the health home team will provide input in the development and assist with the implementation of the discharge and transition plan. The Care Manager is responsible for exchanging or facilitating exchange of medical records such as the care plan, crisis plan, list of current medications, the most recent psychiatrist note and any other medical documents necessary to facilitate continuity of care during a crisis, hospitalization, incarceration or admission to a residential program. Hospital treatment team meetings will be attended by the Care Manager whenever possible or another team member if the Care Manager is not available. Qualified Health Home Specialists will assist with physical discharge process, assisting the client with returning home and community and linking the client to follow-up appointments. The Care Manager will review the discharge records including after-care plan and medications, update care plan accordingly, coordinate with other team members including family, psychiatrist, the hospital liaison worker, nurse and pharmacist and re-engage and re-orient the consumer to the community-based care. The Team Leader will track team clients in crisis, hospitalized or incarcerated, conduct case reviews, review discharge/transition plans, monitor warm hand-off and smooth transition of clients back to community. The methods of health home services delivery will consist of; service delivery to the beneficiary and may include other individuals who will assist in the beneficiary s treatment; service delivery may be face-to-face, by telephone, and/or by video conferencing; and service delivery may be in individual, family or group format; service delivery is not site-specific and the health home services should be provided in locations and settings that meet the needs of the health home beneficiary. Ways Health IT Will Link The State will phase-in use of HIT to support the delivery of CBHC health home services. In recognition of the varying levels of HIT (i.e., electronic medical records, registries, etc.) utilized by CBHC health homes, the State will initially require that CBHC health homes are able to receive utilization data electronically from a variety of sources. The data will, at a minimum, include clinical patient summaries (e.g., diagnosis, medication profiles, etc.) and real-time notifications of a patient s admission to, or discharge from, an emergency department or inpatient facility. Within twelve months of receiving designation as a Health Home provider, the CBHC must acquire (or adopt) an electronic health record product that is certified by the Office of the National Coordination for Health Information Technology. Within twenty-four months of receiving designation as a health home provider, the CBHC must demonstrate that the electronic health record is used to support all health home services, including population management. The CBHC health home will also be required to participate in the statewide Health Information Exchange, when available in their region. HIT supports for Comprehensive Transitional Care involve CBHCs use of electronically received health utilization profiles, which the notify CBHC health home about inpatient hospital admissions. The State will also make health home assignment information available to any Medicaid provider through the secure provider web portal. Providers will be able to access the portal to determine if consumers are enrolled in a health home. Individual and Family Support Services (including authorized representatives) Service Definition Individual and family support services include, but are not limited to, the following: providing expanded access and availability of services along with continuity in relationships between the individual/family, provider(s), and the Care Manager; supporting the delivery of person centered care; assisting with accessing natural support systems in the community; performing outreach and advocacy for the individual/family to identify and obtain needed resources (e.g., transportation); educating and teaching the individual on selfmanagement techniques; facilitating further development of daily living skills; assisting with obtaining and adhering to medication and other prescribed treatments ; providing interventions that address symptoms, and behaviors and assist the health home enrollee in eliminating barriers to seeking or maintaining education, employment or other meaningful activities related to his or her recoveryoriented goal; providing opportunities for the individual/family to participate in the assessment and care plan development/implementation, including providing access to electronic health records or other clinical information; and making referrals to community/social/recovery supports. Health home services will also be delivered in a manner that takes into account the individual s and family s preferences and is culturally and linguistically appropriate. Individuals and their families will be integral to the quality improvement process by providing feedback on experience/satisfaction of care through surveys or by participating in patient/family advisory councils. Individual and family supports will be provided by all members of the team. Clients will be served by a constant core team to assure continuity of relationship and support. CBHC health home sites are expected to provide expanded and enhanced access to staff and services for support and client-centered care. Provision of peer support will be provided by the Qualified Health Home Specialist with peer specialist qualification. Care Managers and Qualified Health Home Specialists will also assist and link clients to natural supports, advocacy organizations, and support or self-help groups in their communities. The methods of health home services delivery will consist of; service delivery to the beneficiary and may include other individuals who will assist in the beneficiary s treatment; service delivery may be face-to-face, by telephone, and/or by video conferencing; and service delivery may be in individual, family or group format; service delivery is not site-specific and the health home services should be provided in locations and settings that meet the needs of the health home beneficiary. Ways Health IT Will Link The State will phase-in use of HIT to support the delivery of CBHC health home services. In recognition of the varying levels of HIT (i.e., electronic medical records, registries, etc.) utilized by CBHC health homes, the State will initially require that CBHC health homes are able to receive utilization data electronically from a variety of sources. The data will, at a minimum, include clinical patient summaries (e.g., diagnosis, medication profiles, etc.) and real-time notifications of a patient s admission to, or discharge from, an emergency department or inpatient facility. Within twelve months of receiving designation as a Health Home provider, the CBHC must acquire (or adopt) an electronic health record product that is certified by the Office of the National Coordination for Health Information Technology. Within twenty-four months of receiving designation as a health home provider, the CBHC must demonstrate that the electronic health record is used to support all health home services, including population management. The CBHC health home will also be required to participate in the statewide Health Information Exchange, when available in their region. HIT supports for Individual & Family Support Services will involve CBHCs use of electronically received health utilization profiles that, auto-generate communications sent to patients and family members of next appointment and establishment of a tickler system (e.g., , postcard, phone call) to remind clients to schedule routine exam (dental exam, vision checks, medical test such as lab work, physical exam, mammogram, etc.). CBHCs will also be encouraged to develop internet capacity for information about wellness, 5/31

6 promotional information, and supports access to services. Referral to Community and Social Support Services Service Definition The CBHC health home will offer and/or arrange for onsite and offsite community and social support services through effective collaborations with social service agencies and community partners. The CBHC health home will identify and provide referrals to community, social, or recovery support services such as maintaining eligibility for benefits, obtaining legal assistance, and housing. The CBHC health home will assist the consumer in making appointments; validate the service was received; and complete any follow up as necessary. Care Managers will be responsible for identifying non-clinical services and needs that require referrals to community and social supports during the comprehensive assessment with input from individual and family and other team members. However, Qualified Health Home Specialists will largely initiate referrals to community resources and social supports, assist with the completion of paperwork, ensure that needed services, resources and supports are acquired and provide status reports and updates to the team. The Team Leader will monitor team s referral process for community and social supports identify/compile community resources and assist with complex cases. The methods of health home services delivery will consist of; service delivery to the beneficiary and may include other individuals who will assist in the beneficiary s treatment; service delivery may be face-to-face, by telephone, and/or by video conferencing; and service delivery may be in individual, family or group format; service delivery is not-site specific and the health home services should be provided in locations and settings that meet the needs of the health home beneficiary. Ways Health IT Will Link The State will phase-in use of HIT to support the delivery of CBHC health home services. In recognition of the varying levels of HIT (i.e., electronic medical records, registries, etc.) utilized by CBHC health homes, the State will initially require that CBHC health homes are able to receive utilization data electronically from a variety of sources. The data will, at a minimum, include clinical patient summaries (e.g., diagnosis, medication profiles, etc.) and real-time notifications of a patient s admission to, or discharge from, an emergency department or inpatient facility. Within twelve months of receiving designation as a Health Home provider, the CBHC must acquire (or adopt) an electronic health record product that is certified by the Office of the National Coordination for Health Information Technology. Within twenty-four months of receiving designation as a health home provider, the CBHC must demonstrate that the electronic health record is used to support all health home services, including population management. The CBHC health home will also be required to participate in the statewide Health Information Exchange, when available in their region. HIT supports for Referral to Community & Social Support Services will involve CBHCs use of electronically received health utilization profiles that connect clients with necessary social supports via phone, fax or web- based commensurate with providers capacity and referral source requirements. v.provider Standards A community behavioral health center (CBHC) must meet state defined core requirements in order to qualify as a provider of health home services for individuals with serious and persistent mental illness (SPMI). CBHCs will be the only provider type recognized by the State as eligible to provide Health Home services for persons with SPMI, The State will contract with the approved CBHC Health Home for the provision of, and payment for, Health Home services. Unless otherwise indicated, CBHCs must meet the following minimum requirements prior to providing health home services: a. Be certified by the Ohio Department of Mental Health as eligible to provide the following Medicaid covered community mental health services: pharmacological management, mental health assessment, behavioral health counseling and therapy, and community psychiatric support treatment. This certification includes achieving accreditation from any of the following national organizations: The Commission on Accreditation of Rehabilitation Facilities (CARF), The Joint Commission, or The Council on Accreditation for Children and Family Services. b. Provide all of the following health home services as necessary and appropriate for beneficiaries: comprehensive care management, care coordination, health promotion, comprehensive transitional care, individual and family supports, referral to community and social support services, and the use of health information technology to support the delivery of health home services. c. Demonstrate integration of physical and behavioral health by: i. Achieving one of the following accreditations at the agency s next accreditation survey : 1) the CARF s Integrated Behavioral Health/Primary Care (IBHPC) Behavioral Health Core Program Standards; or 2) the Joint Commissions Behavioral Health Care Accreditation Program Standards for Primary Physical Health Care; or 3) Council on Accreditation s Integrated Behavioral Health and Primary Care Supplement Standards; or 4) the National Committee for Quality Assurance recognition as a Patient Centered Medical Home (Level 1) within 18 months of becoming a CBHC health home; or 5) equivalent recognition standards as approved by the State. ii. Ensuring that specific medical screening and treatment services, consistent with current professional standards of care, are provided to the Health Home consumer by directly providing the service on-site or assuring the service is provided through a written agreement with a primary care provider. iii. Identifying a single point of contact for each MCP who shall work with the MCP on activities such as the following: informing the MCP of CBHC Health Home Care Management Team meetings, collaborating on the development of the assessment and care plans, facilitating data exchange with the MCP, etc. iv. Establishing policies and written agreements with primary care providers for communication and integration between behavioral health and primary care if the CBHC does not have an ownership interest in a primary care organization or does not have embedded primary care services. v. Establishing effective partnerships and referral/coordination processes with specialty providers, inpatient facilities, and managed care plans that support the delivery of health home services. a. The CBHC must establish a partnership and a referral/coordination process with specialty providers and inpatient facilities. At a minimum, the referral/coordination process must address the roles of the CBHC and the partnering provider in coordinating and managing care for the consumer, including any necessary follow up with the consumer. The process shall include how and what type(s) of information will be exchanged in a HIPAA compliant manner between the CBHC and the partnering specialty provider or inpatient facility. b. The CBHC must establish partnerships with managed care plans in the service area and develop written policies and procedures that include the following: i. Notifying the MCP of referrals received by the CBHC for the MCP s members, and of any MCP member who is currently receiving health home services. The CBHC Health Home will collaboratively develop a transition plan with the MCP for any plan member that will receive health home services in order to prevent unnecessary duplication of, and avoid gaps in services. ii. Forming a Care Management team that includes the CBHC Health Home core team, the health home enrollee, the enrollee s family/supports, the enrollee s primary care provider, and other providers, as appropriate, and the enrollee s managed care plan in order to effectively manage the enrollee s needs. 6/31

7 iii. Working collaboratively with the MCP to ensure all of the member s needs identified in the CBHC health home care plan are met. Ensure that the care plan is accessible to the MCP and providers involved in managing the enrollee s health care. iv. Requesting care coordination supports from the MCP, if needed. v. Collaborating with the MCP s designated single point of contact on such activities as the following: exchanging information about the plan s member, soliciting input to the development of the care plan, participating in Health Home team meetings, and assuring access to services that are outside the scope of the CBHC. vi. Ensuring that if the CBHC has direct ownership of a primary care provider/practice that it seeks a contract with the MCPs in the service area for the provision of primary care services. If the CBHC has a co-located relationship or a referral/coordination relationship with a primary care provider for the provision of primary care services, the CBHC shall encourage the provider to seek a contract with the MCPs in the service area. vii. Ensuring that the CBHC s collaborative care agreements are primarily with primary care providers who are contracted with the MCPs in the service area. Ensure that any established partnerships and referral/coordination processes with specialists and inpatient facilities, if applicable, also include those contracted with the MCPs in the service area. The CBHC shall work with the MCP to understand how credentialing may impact partnering providers who do not have current contracts with the MCPs in the service area. The CBHC shall also: a. Provide a list of primary care providers and specialists/inpatient facilities to the MCP, for which the CBHC has integrated care agreements and referral/coordination processes, respectively. The CBHC shall refer to the plan s panel of providers when assisting the enrollee in obtaining necessary health care. b. Collaborate with the MCP to ensure that the enrollee s selected/assigned PCP has a current, collaborative care agreement with the CBHC. If the enrollee requests a change to the selected PCP, the CBHC shall inform the MCP so that the plan s existing process to change the PCP is promptly initiated. viii. Providing timely notification of all inpatient facility discharges and residential setting transitions to the managed care plan in order to ensure adequate and timely provision of follow up care. The CBHC Health Home will ensure that a discharge/transition plan is in place prior to the enrollee s discharge or transition. The CBHC will work with the MCP to ensure that post discharge services are prior authorized, if appropriate, and provided by the plan s contracted providers. The CBHC must ensure that the discharge/transition plan is integrated into the plan of care and communicated to the Care Management Team. ix. Having the capacity to send electronic data to MCPs and to produce ad hoc reports to more effectively coordinate care. d. Support the delivery of person-centered care by providing: i. Expanded, timely access to health care services provided by the health home provider; ii. Orientation of the patient to health home services; The CBHC must provide the patient, family and caregivers with verbal information and/or written materials in a manner that is appropriate for the patient s needs and includes the following: an overview of health home services and how the consumer will benefit from the services; the ability to decline the services or terminate participation in the program; and how the patient, family and caregivers may participate in the delivery of health home services. iii. Services that are delivered to the patient/family in a culturally and linguistically appropriate manner; The CBHC must assess the racial and ethnic diversity of the population served and ensure that patients receive care in a way that is compatible with their cultural needs. The CBHC must record all special communication needs of the consumer in the care plan and the provision or related services offered to the consumer (e.g., identification of a hearing impairment and provision of sign language services). The CBHC must attempt to recruit and retain staff who are representative of the demographic(s) of the population served. iv. A multi-disciplinary team based approach for the delivery of Health Home services through the ongoing use of an established team of members defined by the state; Each CBHC health home will determine, assemble and maintain appropriate Health Home Team FTEs that are necessary to provide health home services and achieve the necessary health home outcomes. CBHC health home team members must consist of: Health Home Team Leader: Provides administrative and clinical leadership and oversight to the health home team and monitors provision of health home services. The minimum qualifications for the team leader position consist of a Master s Degree or higher in a healthcare related field with appropriate or applicable independent licensure(s) (LISW, PCC, IMFT, RN-MSN, licensed psychologist) as well as supervisory, clinical and administrative leadership experience. The state may consider other Master s Degree-level professionals in a healthcare related field such as a Master s Degree in public health, health management, and health administration and not require independent clinical licensure. Embedded Primary Care Clinician: Participates in the provision of health home services including identification of consumers, assessment of service needs, care plan development, development of treatment guidelines, and monitoring of health status and service use. The Embedded Primary Care Clinician role can be conducted by any of the following professionals: primary care physicians, pediatricians, gynecologists, obstetricians, Certified Nurse Practitioners with a primary care scope of practice, Certified Nurse Specialists with a primary care scope of practice, and Physician Assistants. Care Manager: Be accountable for overall care management and care coordination and able to both provide and coordinate all health home services. The minimum qualifications for the Care Manager include social workers with LSW or LISW, counselors with PC or PCC, Marriage and Family Therapists with MFT or IMFT, RN Nurses (including a 2 or 3 year RN degree) with extensive experience working with the SPMI population, and other qualified staff approved by the State. Qualified Health Home Specialist: Assists with and provides care coordination, referral/linkage, follow-up, family/consumer support and health promotion services. The minimum qualifications for the qualified health home specialist are LPN nurses, CPST workers with four year degrees or 2 year Associate Degrees, wellness coaches, peer support specialists, certified tobacco treatment specialists, health educators and other qualified workers (e.g., community health workers with Associate Degrees or CPST workers with commensurate experience). v. A single, integrated, person-centered care plan that coordinates all of the clinical and non-clinical needs; The single integrated care plan must identify the consumer s needs (as identified in the comprehensive assessment), goals, interventions, and expected outcomes. The CBHC must provide an opportunity for the patient, family members, caregivers, and providers to offer input to the care plan. The care plan must be reviewed no less frequently than once a quarter and updated as appropriate. vi. The ability to track tests and referrals for health care services, and coordinate follow up care as needed; 7/31

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